Palliative Care Case Study Of Bill And Neville Discussion

Palliative Care Case Study Of Bill And Neville Discussion

Bill is an 83-year-old resident of an aged care facility.  He has dementia and end stage heart failure secondary to advanced coronary artery disease. Len is Bill’s son and enduring guardian, and visits Bill daily. Bill and his son are very close and prior to moving into the aged care service Bill lived with Len for 5 years. Len comes to the aged care service and has lunch with Bill every day.

Over the past three months Bill has become immobile, physically frail and has had recurrent chest infections. Len has recognised that his father’s condition is deteriorating and has discussed with the staff that he does not want his father to suffer. Over the past week, Bill has been unable to leave his bed, due to another chest infection. Despite being prescribed  Amoxicillin (antibiotic), Bill has continued to deteriorate further with a diagnosis of bronchopneumonia. Bill is now refusing food and fluid and he is quite sleepy.  The RN at the service and Bill’s GP meet with Len to discuss his father’s deterioration. The GP informs Len that Bill is no longer able to swallow and recommends that all oral medications be ceased. Len agrees with the decision to treat Bill palliatively and explains that he wants his father to have a peaceful death. Bill has commenced on an end-of-life care pathway and Len has been encouraged to spend as much time as he needs with his father Palliative Care Case Study Of Bill And Neville Discussion.

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The RN at the service has done a Braden Pressure Ulcer Risk Assessment for Bill and he has scored 8 (severe risk). Bill has been placed on a pressure relieving mattress (alternating air pressure mattress). Bill is also incontinent of urine and faeces. Incontinence pads are being used. Subcutaneous PRN analgesia has been charted for pain management. When staff move Bill in bed he is assessed having an Abbey Pain Score of 13 (moderate pain).

Len has spent many days sleeping in the visitor’s room. Len is worried about his father’s death and unsure what will happen to his father as he continues to deteriorate.

You are reviewing sections of Bill’s care plan since the decision to treat him palliatively was made.

Domain	Nursing Goal	Intervention
Nutrition and Hydration	Encourage Bill to increase his oral intake	Provide Bill with nutritional supplements to increase intake and weight gain. Offer Bill regular drinks.
Oral Health	Maintain moist lips and oral mucosa	Clean Bill’s teeth three times a day to avoid bacterial build up. Inspect Bill’s mouth on a daily basis for signs of dryness and infection. Use oral swabs soaked with water or normal saline.
Skin Care	Maintain skin integrity	Reposition Bill every 2 hours to promote circulation and reduce pressure on bony prominences.

Using the information presented in Bill’s case study and care plan to answer the following five (5) questions.

1. Refer to the nutrition and hydration domain. Explain whether the nursing intervention is appropriate for Bill and identify one (1) other intervention for Bill.

Nursing Goal And Intervention To Support Len, Bill’s Son

The issues of feeding and food are considered to be important factors that are addressed in palliative care, as they enhance the quality of life of the patient and assist the professionals in managing the patient’s symptoms (1; 2). As Bill had become physically frail and could not recover from his chest infection after antibiotic therapy, nutritional assistance would help in enhancing his condition. Moreover, repositioning patients as frequently as two hours, promotes blood circulation and relieves pressure injuries (3). Therefore, the nursing intervention developed for addressing the hydration and nutrition domains of Bill were appropriate. One other intervention for Bill that could be developed by the nurse would be the alteration in medication to treat bronchopneumonia, preferably a drug that can be administered through respiratory or other route as Bill is experiencing trouble with swallowing (4).

2. Based on your response to Question 1 explain how the nutrition and hydration intervention that you have identified will protect Bill’s human rights?

The nutrition and hydration intervention that was identified protects the human rights of the patient by upholding his right to nutritional care (5). Someone who is unable to reach their nutritional requirements and suffers consequences, must be provided nutritional support by a professional within the team of care providers. This upholds their right to be fed and receive therapy concerning the nutritional requirements (6).

3. Refer to the Oral Health domain of Bill’s care plan. Explain two (2) limitations of the interventions that are documented.

Brushing thrice daily would lead to abrasion of the patient’s enamel and might cause gum problems it is recommended that they brush their teeth twice daily. In addition, the patient would require assistance with brushing their teeth as they are physically frail (7 NIH, 2018)Palliative Care Case Study Of Bill And Neville Discussion.

4. Reflecting on the information provided in the scenario, identify three (3) skin care interventions and explain how each intervention can support Bill’s needs and quality of life at this stage.

The skin needs to be moisturized frequently, using powder when repositioning the patient and regularly cleaning and drying the patient. Moisturizing would prevent the breakdown of Bill’s skin, use of powder during repositioning would prevent frictional injuries and regular cleaning and drying would ensure that pressure injuries are managed (8).

5. Document an appropriate nursing goal and nursing intervention to support Len (Bill’s son).  Fill-in the below table: goal and intervention.

Domain	Goal	Intervention
Mental health	Help Len in reducing his concerns about the father’s condition	Providing Len with accurate information and suggesting group therapy to manage his mental wellness. Len could be provided support to cope with the stress and encouraged to have hope (9).

Mr Neville Hunt is an 83-year-old widower who lives on his own. He has three children who live within a 30-minute drive from his house. Neville has a history of mild hypertension, vision impairment due to age-related macular degeneration (AMD), hearing loss and osteoarthritis. Neville is usually independent at home and enjoys seeing his grandchildren and playing chess with his sons on the weekend.

Nursing Goal And Interventions For Patients With Delirium In Neville’s Case

Neville’s daughter, Catherine, is concerned because she finds her father agitated one morning, walking around the house without his clothes on and not wearing his glasses or hearing aids. Catherine calls an ambulance and Neville is taken to hospital for further assessment.

On arrival at the ED, Neville is given a triage category of 2. His observations are as follows:

HR 97,  BP 170/90,  T 37.5, RR 22,   Sa02 80% RA.

Medications include: Lisinopril 10 mg po daily, Caltrate 6000units daily, Panadol Osteo 825mg tds.

Neville is waiting to be seen by the ED medical officer. He appears slightly breathless and is warm to touch.  At times he is not responding to questions and appears disorientated and distracted.

The Registered Nurse assigned to Neville in the ED conducts the assessment test for delirium and cognitive impairment (4AT). Neville scores 11 (high risk of delirium). The findings of the assessment show that Neville:

• has a high level of alertness (hypervigilance);
• is unable to state the name of the hospital, but can recall his age, date of birth and the current year;
• his daughter reports that his condition changed rapidly in the last 24 hours.

The RN also conducts a Montreal Cognitive Assessment (MOCA) and on this Neville scores 27/30 which is considered normal.

After consulting with medical staff, an initial nursing care plan (see below) has been developed for Neville based on the provisional diagnosis that he has a delirium.

Domain	Nursing Goal	Interventions
Mental and cognitive status	Alleviate symptoms of a possible delirium	Minimise noise and stimulation: ·         Minimise interaction with Neville to avoid him becoming further agitated ·         Do not fit hearing aids for Neville as hearing excess noise from the ED may increase agitation and confusion.
	Maintain Neville’s safety	·         Keep the curtains to Neville’s cubicle open at all times so that staff can monitor him visually and make sure he does not fall. ·         Place bedrails up so that Neville cannot climb out of bed. ·         Make sure Neville is wearing his glasses. ·         Encourage daughter to be present to provide a sense of familiarity and security.

Using the information presented in Neville’s case study and care plan to answer the following five (5) questions.

1. Considering Neville’s presentation, explain why it was important for the RN to conduct the 4AT and the MOCA.

It was important to conduct the cognitive assessments as the patient presented signs of delirium. The assessment techniques aid the professionals in clarifying the presence of a cognitive condition. It also assists in the prediction of falls and other complications (10)Palliative Care Case Study Of Bill And Neville Discussion.

2. Consider the nursing interventions for the mental and cognitive status domain of Neville’s care plan. Do both of these interventions promote Neville’s autonomy? Explain why/why not.

The interventions included in the care plan do not promote the autonomy of Neville. Removing hearing aids might reduce the excess noise, nevertheless it is proven that sensory deprivation leads to increased chance of agitation in delirium patients, moreover, it would make Neville dependent on the professionals for communication (11). Moreover, limited interaction will increase the agitation in the patient as they might become confused. Moreover, it is necessary for professionals to ensure that patients carry their hearing aid and other aids if required (12).

3. Evaluate the Interventions that are documented to maintain Neville’s safety. Identify one (1) intervention that does not protects Bill’s human rights and provide an alternative person-centred intervention. To answer this question, fill in the below table.

Which intervention does not protect Bills human rights ?	Which Human right is not protected and why	Detail an alternative intervention
Installation of bed rails to prevent him from climbing out.	Right to freedom from torture (13)	To prevent Neville from wandering he should be kept under supervision and installing alarms on bed will also alert the professionals when he leaves his bed (14).

4. Identify from the care plan which two interventions that are most appropriate for maintaining Neville’s safety and explain why.

The two interventions that preserve Neville’s safety were keeping the curtains to his cubicle open and prompting his daughter to be involved in the care by being present. The intervention of keeping the curtains open at all times ensures that the nurses can always assess his condition and ensure there is no possibility of a fall (15). Encouraging the daughter to visit Neville maintains his security by reducing anxiety as he can establish the environment to be safe, therefore allowing him to remain calm in the professional environment. Reduction in anxiety would result in the patient not becoming agitated, thus reducing the chance of harming themselves (16).

5. What key information should the nurse be providing to Neville’s daughter about delirium?

The daughter should be provided with the care plan and must be informed about the importance of surveillance to prevent Neville from harming himself. The daughter must also be informed about the strategies to manage his agitated state and bring him back to a calm state. She must also be informed about the importance of aids such as hearing aid and glasses as these would prevent confusion and recurrence of the incident that was highlighted in the case study (17).

Mr Richard Chen is an 80-year-old man who lives at home with his wife, Fiona. Richard was a car mechanic for 40 years and ran his own auto-mechanic business. Richard always loved old cars and owned a number of vintage vehicles, which he worked on as a hobby. He was an active member of a local car club for 30 years and enjoyed attending the monthly meetings. Between his business and hobbies Richard was always a busy man. Richard and Fiona have two children, both of whom live interstate with their own families.

Richard was diagnosed with Alzheimer’s dementia 7 years ago. He has significant short term memory loss and requires reminding and prompting from his wife as to their usual daily activities. Richard requires assistance with his ADLs. For example, Fiona assists Richard to dress, prompts him to clean his teeth by leaving the toothbrush on the bench with toothpaste on it and sets him up for his shower. Once set up, Richard is able to shower and dry himself. Richard is continent at home and is able to feed himself once Fiona has set him up for a meal.  Richard has developed an expressive aphasia and this symptom becomes more severe when he is upset or worried. Fiona has found caring for Richard to be more challenging as result of his expressive aphasia because he often has difficulty verbalising his needs.

Richard has recently been admitted to an aged care service for respite while Fiona travels interstate to visit one of her sons. Richard is directed by staff to a large dining room for his meals. There is often a lot of staff movement in the dining room as meals are served. However, often before Richard’s meal is served, he gets up from the table and walks away. A member of staff usually follows him and takes him by the arm and leads him back to the table. Richard often refuses to sit and will walk away. Recently when a staff member tried to redirect him back to the table, for a third time Richard grabbed her hand and squeezed it hard while saying in a concerned voice “no, no, no”. The staff member was startled by Richard’s response and withdrew from the interaction.

One evening after Richard walked away from the dining room and did not return to have his dinner, he was found in another resident’s room, which is next to his room. He is dressed in the other resident’s pyjamas with his underpants over the pyjama pants. When the staff member enters the room, she finds Richard eating a packet of biscuits that belongs to the other resident.

You are asked to contribute to an interim care plan for Richard which will be used to direct care during his stay. Another staff member has started writing the care plan and you review the nutrition and hydration and activities of daily living domains (see below)Palliative Care Case Study Of Bill And Neville Discussion.

Domain	Nursing Goal	Intervention
Nutrition and Hydration	Ensure that Richard’s nutritional needs are met.	·         Direct Richard to the dining room. ·         At times Richard will not remain at the dining table for his meals – staff need to redirect him back to the table regularly.
Activities of daily living	Ensure that Richard is supported to attend to his ADLs	·         Provide physical assistance to Richard in the shower. ·         Provide regular prompts for toileting, ensure that the toilet door is left open in Richard’s room. ·         Verbally prompt Richard to clean his teeth morning and evening.

Using the information presented in Richard’s case study and care plan to answer the following five (5) questions

1. Richard displays a number of common symptoms related to his dementia in the scenario. Identify the symptom (1 mark) that has caused Richard to put on his underpants over his pyjama pants and explain one (1) intervention that could enable Richard to dress successfully.

Richard wore his underpants over the pyjama pants due to his symptom of short term memory loss. Assisting Richard with dressing up would enable him to dress successfully. Helping Richard to dress up in the same way his wife would assist him by prompting him the order of clothes that are worn sequentially would enable him to dress successfully (18)

2. Identify and explain two (2) unmet needs that likely contributed to Richard leaving the dining room and being found in another resident’s room?

Lack of surveillance and no staff member that followed him like they usually would, contributed to him leaving the dining area and entering another resident’s room. Patient supervision by nurses protects the patients and the staff members from any harm that might occur. Moreover, following patients that have a tendency to wander prevents the patient from leaving the facility as they might be in a confused state, and as Richard suffered from short term memory loss, assistance and supervision were the significant needs that were unmet (19).

3. For the two (2) unmet needs you have identified in Question 2 (above) identify a person-centred intervention for each need that could be added to Richard’s care plan. To answer this question, fill in the table below.

Unmet need	Intervention (2 marks per intervention)
1.      Patient supervision	Coordinating the care with other nurses so that Richard is kept under surveillance at all times (20)
2.      Assisting patient	The staff should be motivated to improve their knowledge of Richard’s condition and provide compassionate care (20)

4. Review the three (3) interventions in the activities of daily living domain of Richard’s care plan and explain whether each intervention is or is not enabling.

Providing assistance to the patient in the shower, providing regular toileting prompts and verbal prompts for brushing twice a day were the interventions that enabled Richard as he could successfully complete activities of his daily life and maintain good hygiene (21).

5. Explain how you would understand Richard’s behaviour when he squeezes the staff member’s arm and states “no, no, no”.

It can be understood that Richard was not ready to go back to the dining room due to an incident that might have occurred or it could have been the unfamiliarity with the environment. As Richard suffers from aphasia, he is unable to express his concerns and that could have been his way of insisting that he is not taken back to the room. Aphasia in Alzheimer’s can cause functional and behavioural decline that might have led to Richard not being able to identify his grip being hard when he refused to go back (22)Palliative Care Case Study Of Bill And Neville Discussion.

Mrs Elizabeth Blair is 67 years of age, and lives on her own. Elizabeth is an ex-smoker and her medical history includes asthma, chronic bronchitis and worsening emphysema (diagnosed 3 years ago). She has been under the care of a respiratory physician who recommended some simple breathing exercises at the last visit. Elizabeth’s symptoms now include breathlessness which she manages with a bronchodilator medication and oxygen therapy prescribed by her GP. She does not always use the oxygen to relieve her breathlessness in a timely way. This often results in debilitating fatigue, resulting in Elizabeth not being able to perform her personal hygiene, or prepare her own meals. Elizabeth describes her fatigue as having a negative impact on her quality of life and at times can leave her feeling lonely and socially isolated.

On good days, Elizabeth likes doing crossword puzzles and reading the daily newspaper. She enjoys her local friends paying a visit and her son who visits her most weekends when she is feeling well. Elizabeth’s constant companion is her little dog which she loves dearly. Sadly, she cannot walk the dog anymore, but her son takes her dog for a walk when he is able to visit.

Elizabeth is receiving fortnightly telehealth calls from a community nurse who is recording her oxygen saturations. Today’s oxygen saturation recording was 89% on room air. Elizabeth has said she wants a break from the house and would like to go down the coast to visit her son. She is not sure she wants the trouble of taking her oxygen equipment with her.

Elizabeth’s son has asked some questions about his mother’s prognosis and indicates that he wants to be included in a discussion on Elizabeth’s future goals of care with her health care team. A meeting has been arranged with Elizabeth’s GP and community nurse.

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The following information is included in Elizabeth’s care plan.

Domain	Nursing Goal	Intervention
Activities of daily living	Elizabeth performs personal hygiene every day.	Elizabeth is encouraged to shower first thing in the morning when she gets out of bed.
Symptom management	Elizabeth uses her bronchodilator every day as required	Direct Elizabeth to use her bronchodilator everyday regardless of whether or not she feels breathless.

Using the information presented in Elizabeth’s case study and care plan to answer the following five (5) questions

1. Based on the information provided about Elizabeth identify what is important to Elizabeth (2 marks) and what is important for Elizabeth (2 marks). To answer this question, fill in the table below.

What is important to Elizabeth?	What is important for Elizabeth?
Dog	Maintaining personal hygiene
Friends paying her a visit	Maintaining her food intake
Spending time solving crossword and reading the paper	Using oxygen therapy
Visiting her son	Continuing medication

2. Based on the information you have provided for Question 1 identify a SMART goal for Elizabeth.

S- Improving breathlessness and avoiding fatigue

M- Recording her oxygen saturation and her feedback on condition of fatigue

A-Providing oxygen through mask and carrying the oxygen cylinder so that it is accessible

R- It will help her in managing breathlessness and perform basic activities that will improve her overall health

T- The goal will be attained in 72 hours

3. Describe in your own words what is meant by dignity of risk and explain how supporting Elizabeth’s desire to visit her son accepts the dignity of risk in Elizabeth’s case.

Dignity of risk is the idea of dignifying an individual’s right to make decisions and take “reasonable risk.” Not allowing an individual this right threatens their self-esteem and affects their quality of life (23). Supporting the decision of Elizabeth to visit her son accepts the dignity of risk in her case as there is the reasonable risk of aggravating her breathlessness, but she would be improving the quality of her life.

4. Explain three nursing interventions that can be put in place to support Elizabeth’s Goals of Care. To answer this question, fill in the table below.

Goals of care	Intervention
To enable Elizabeth to continue living at home.	Telehealth (24)
Management of Elizabeth’s breathlessness.	Encouraged to take her bronchodilator medication and oxygen therapy. The telehealth nurse could inquire about her implementing these (24).
To provide support to Elizabeth and her son.	Including Elizabeth’s son in developing the plan of care. Informing Elizabeth and her son on the benefits of the prescribed therapy. Moreover, involving her son in the care would provide psychological support to Elizabeth (25).

5. Identify three (3) members of the multidisciplinary team that would be well placed to assist Elizabeth to manage her symptoms.

General Practitioner, Nurse, pulmonologist.

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